Empiric Treatment of Classical Pyoderma Gangrenosum in the Outpatient Setting: A Case Report.

Pyoderma gangrenosum (PG) is a rare neutrophilic disorder that typically presents as painful, ulcerative lesions. It is a diagnosis of exclusion and is oftentimes associated with systemic conditions such as inflammatory bowel disease, rheumatoid arthritis, and other inflammatory conditions. PG remains difficult to diagnose, and a delay in recognizing the disease can contribute to appreciable morbidity in the population. Here, we present the case of a 42-year-old male with the classical subtype of PG in the outpatient clinic who failed three courses of antibiotics before responding to corticosteroids.

The Incidence of Skin and Soft Tissue Infections in the United States and Associated Healthcare Utilization Between 2010 and 2020.

Background: The number of patients with skin and soft tissue infections (SSTIs) in the United States appeared to be increasing well into the 21st century. However, no recent data have confirmed this trend. Methods: This retrospective, observational cohort study used claims data over 11 years (2010-2020) from Optum's de-identified Clinformatics Data Mart Database. SSTI episodes, complications, and comorbidities were identified using International Classification of Diseases codes. Annual SSTI incidence rates, proportions of recurrent SSTI, SSTI-associated deaths, and total costs were estimated. Results: During the study period, 5.4 million patients experienced 9.1 million SSTI episodes, with an incidence of 77.5 (95% confidence interval, 77.4-77.5) per 1000 person-years of observation (PYO). Annual incidence did not change significantly over time. Overall incidence (per 1000 PYO) of SSTI episodes in patients without comorbidities was 32.1 (highest incidence was for previous SSTI [113.5]) versus much higher rates if comorbidities were present. Incidence rates (per 1000 PYO) of chronic ulcers increased over time from 11.3 to 18.2 (P < .0001) and complicated disease from 3.5 to 6.3 (P < .0001). Deaths occurring within 30 days post-SSTI hospitalization rose from 2.6% to 4.6% in 2020. Recurrences occurred in 26.3% of index cases. The mean cost of an SSTI episode was US$3334 (median US$190) and was highest for surgical site infections and chronic ulcers. Conclusions: The epidemiology of SSTI in the United States is changing and the disease burden is increasing despite stabilization in overall incidence. These data can inform identification of priority populations who could benefit from targeted interventions.

Chronic Idiopathic Ulcers Mimicking Cecal Carcinoma: A Case Report.

Chronic idiopathic ulcers of the colon pose diagnostic challenges due to their elusive etiology and potential resemblance to other intestinal pathologies, such as cecal carcinoma. This case report outlines the clinical course of a 68-year-old female patient who presented to the emergency department (ED) with persistent right lower quadrant pain. Despite multiple hospital visits yielding varied diagnoses, a definitive diagnosis was only made following a laparoscopic partial colectomy, which revealed chronic idiopathic ulcers with transmural scarring and adhesions to adjacent small intestine loops. Histological examination demonstrated a substantial ulcer bed populated by inflammatory cells, including large stellate and spindled stromal cells within the granulation tissue, alongside lymphoid hyperplasia and scar tissue extending into the muscularis propria. The initial presentation of this case could easily be mistaken for appendicitis, diverticulitis, carcinoma, or irritable bowel syndrome, highlighting the significance of considering chronic idiopathic ulcers in the differential diagnosis of patients presenting with cecal masses.

A case report on rare finding of microfilaria in pus sample of an ulcer over elephantiasis leg.

Skin ulcerations are a significant cause of morbidity and can be challenging to manage. Among the various causes of chronic non-healing ulcers, lymphedema is also considered a possible diagnosis in countries such as Nepal. Lymphatic filariasis has been a significant public health issue in endemic areas. Wuchereria bancrofti is a common nematode parasite that causes lymphatic filariasis. Excessive retention of lymphatic fluid in the interstitial compartment can cause localized tissue swelling, known as lymphedema, which is caused by impaired lymphatic drainage. Microfilariae can be detected in peripheral blood, body fluids, and needle aspirates. Microfilaria is not commonly found in ulcers on elephantiasis legs. We discuss here a case of 73-year-old women with elephantiasis legs with pus discharging ulcers in the thighs. Microscopic examination of pus discharge revealed microfilaria which highlights the importance of pus examination as diagnostic modality in endemic countries.

A 55-Year-Old Male With Systemic Gout Complicated by Septic Shock.

Tophaceous gout is the systemic deposition of uric acid which can induce cutaneous ulceration. We present the case of a 55-year-old male with chronic tophaceous gout whose initial presentation was complicated by septic shock due to methicillin-sensitive Streptococcus aureus bacteremia and superinfection of many of his affected joints. The case and discussion will focus on the extent of his infections and approaches to preventative care.

What's old is new again: Insights into diabetic foot microbiome.

Diabetes is a chronic disease that is considered one of the most stubborn global health problems that continues to defy the efforts of scientists and physicians. The prevalence of diabetes in the global population continues to grow to alarming levels year after year, causing an increase in the incidence of diabetes complications and health care costs all over the world. One major complication of diabetes is the high susceptibility to infections especially in the lower limbs due to the immunocompromised state of diabetic patients, which is considered a definitive factor in all cases. Diabetic foot infections continue to be one of the most common infections in diabetic patients that are associated with a high risk of serious complications such as bone infection, limb amputations, and life-threatening systemic infections. In this review, we discussed the circumstances associated with the high risk of infection in diabetic patients as well as some of the most commonly isolated pathogens from diabetic foot infections and the related virulence behavior. In addition, we shed light on the different treatment strategies that aim at eradicating the infection.

Quality registry improves the data of chronic ulcers: Validation of Tampere Wound Registry.

Quality registries are potential tools for improving health care documentation, but the quality and completeness of each registry should be ensured. This study aimed to evaluate the completion rate (completeness) and accuracy of data, first contact-to-registration time (timeliness), and case coverage of the Tampere Wound Registry (TWR) to assess whether it can be reliably used in clinical practice and for research purposes. Data from all 923 patients registered in the TWR between 5 June 2018 and 31 December 2020 were included in the analysis of data completeness, while data accuracy, timeliness and case coverage were analysed in those registered during the year 2020. In all analyses values over 80% were considered good and values over 90% excellent. The study showed that the overall completeness of the TWR was 81% and overall accuracy was 93%. Timeliness achieved 86% within the first 24 h, and case coverage was found to be 91%. When completion of seven selected variables was compared between TWR and patient medical records, the TWR was found to be more complete in five out of seven variables. In conclusion, the TWR proved to be a reliable tool for health care documentation and an even more reliable data source than patient medical records.

Ayurvedic management of venous ulcer - a case report.

Vrana (ulcer), in Ayurveda is defined as a structural deformity in the skin and deeper structures (gaatra avachurnana), associated with ruja (pain), srava (discharge) etc and caused either by the vitiation of the doshas(humuors of the body) or by trauma. Vrana is basically of 2 types- Dushta vrana and Shudha vrana. Shudha Vrana (acute ulcer) is easily treatable, whereas Dushta vrana is a chronic ulcer, mostly unresponsive to any treatment. Acharya Sushruta has described sixty methods for treating such vranas (ulcers). In this case, symptoms like Deerghakalaanubandhi (chronic), Teevra ruja (painful), Teevra puti srava (smelly discharge) etc. were suggestive of Pitta pradhana Sarakta Tridoshaja Dushta vrana on the left leg. Studies from India about the prevalence of venous leg ulcers (VLU) are limited. The chronic wound management strategies include compression therapy and antimicrobial therapy (if infected). However, in unresponsive cases, surgery (skin grafting) is done. A 38-year-old non-diabetic, non-hypertensive female sought Ayurvedic treatment after a wound on her left leg did not respond to the conventional medicines even after 7 months of treatment. The ulcer was painful and foul-smelling, to the extent of disturbing her sleep and restricting her daily activities. Her Ayurvedic treatment comprised of Patoladi kashaya, Kaishora guggulu, Guduchyadi kashaya, Manjishtadi kashaya and Avipathi churna, orally and Vrana prakshalana (wound cleaning) and Vrana lepa (application of medicinal paste) externally. Ayurvedic treatment was effective in healing the Dushta vrana completely in this case. This suggests the efficacy of Ayurveda in the management of chronic ulcers. However, a detailed study of the same with larger sample sizes will help to formulate a treatment protocol for such cases.

Treatment of Diabetic Foot Ulcers With Inforatio Technique to Promote Wound Healing: A Feasibility Trial.

Chronic foot ulcers have extensive consequences for diabetic patients' quality of life and increase risks of amputation and death. The aim of this trial was to assess the feasibility of conducting a larger clinical trial to evaluate the clinical effect of inforatio technique on healing of diabetic foot ulcers (DFUs). Inforatio technique is a novel minimal invasive procedure where small cuts are made on wound beds with punch biopsy tools. This study was a feasibility trial conducted at an outpatient wound care clinic at Zealand University Hospital. Twelve patients with DFUs were included. During a 90-day follow-up, participants visited the clinic 5 times and received inforatio technique twice. Feasibility was assessed with regard to recruitment, acceptability, burden, benefits, protocol adherence, and adverse events. The recruitment rate was 1 patient per eighth day (95% confidence interval [CI] = [4th-13th]), and the retention rate was 100% (95% CI = [74-100]). During follow-up, healing was observed for 4 ulcers (33%, 95% CI = [10-65]) with a mean time for healing of 59 days (range, 22-89) (95% CI = [5-113]). Five ulcers had a reduction of wound area and 3 ulcers had an increase in area from baseline to 90-day follow-up. No temporal relationship was found between inforatio application and wound area increase. There were no patient-reported harmful effects and no adverse events with probable relation to inforatio technique. Patient acceptability and participant adherence were promising. Thus, a larger clinical trial for evaluating the clinical effect of inforatio technique is considered feasible to conduct.

Semisolid Wet Sol-Gel Silica/Hydroxypropyl Methyl Cellulose Formulation for Slow Release of Serpin B3 Promotes Wound Healing In Vivo.

Foot ulcerations are a disabling complication of diabetes and no treatment is currently available based on disease mechanisms. The protein serpin B3 (SB3) was identified as a positive biomarker of successful diabetic wound healing; therefore, its exogenous administration may promote healing. The topical administration of SB3 is challenging due to its protein nature. Physical entrapment in wet sol-gel silica can stabilize the protein's conformation and permit its sustained delivery. However, irreversible syneresis and poor viscoelastic properties hamper wet sol-gel silica application as a semisolid vehicle. To overcome these limits, a sol-gel silica/hydroxypropylmethylcellulose (HPMC) hydrogel blend was developed. SB3 entrapped in 8% SiO2 wet sol-gel silica preserved its structure, was stabilized against denaturation, and was slowly released for at least three days. Blending a silica gel with an HPMC-glycerol (metolose-G) hydrogel permitted spreadability without affecting the protein's release kinetics. When administered in vivo, SB3 in silica/metolose-G-but not in solution or in metolose-G alone-accelerated wound healing in SB3 knockout and diabetic mouse models. The results confirmed that SB3 is a new pharmacological option for the treatment of chronic ulcers, especially when formulated in a slow-releasing vehicle. Silica-metolose-G represents a novel type of semisolid dosage form which could also be applied for the formulation of other bioactive proteins.

Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA.

Xylazine, an alpha-2 adrenergic receptor agonist typically used as a sedative and analgesic in veterinary medicine, is being illicitly supplied to persons who inject drugs (PWID), especially in Puerto Rico and Philadelphia, Pennsylvania in the USA. There is a high prevalence (up to 78%) of xylazine in fentanyl in these areas and also a steep increase in fatalities from its overdose. In this case report, we discuss a case of xylazine-induced skin ulcers in a PWID in the city of Philadelphia. The patient is a 37-year-old female who was injecting about eight to ten "bags" of "dope" (fentanyl, which is typically mixed with xylazine in Philadelphia) every day. She typically injected into her veins on the hands and sometimes into the legs. She presented with ulcers on her lower extremities extending from the knees to ankles, associated with copious purulent drainage and a foul smell. There was extensive necrosis of the subcutaneous tissues, abscesses, and tibial osteomyelitis. This led to multiple hospitalizations with bacteremia from Strep pyogenes, methicillin-resistant Staphylococcus aureus, methicillin-sensitive S. aureus, Enterococcus faecalis, Escherichia coli, and Proteus requiring intravenous antibiotics. She required debridement of the wounds and topical care to treat them. In the areas with a high prevalence of the use of xylazine mixed with fentanyl or heroin, abscesses, and painful skin ulcers are very often reported. The mechanism is thought to be due to its direct vasoconstricting effect on local blood vessels and the resultant decreased skin perfusion. Prolonged use can lead to decreased perfusion and impaired wound healing, leading to higher chances of infection of these ulcers. In addition to the topical effect of vasoconstriction, xylazine also leads to hypotension, bradycardia, and respiratory depression. A skin ulcer in a PWID, similar to the ones reported in our case, should raise clinical suspicion for the presence of xylazine in opiates and other substances.

Management of Chronic Ulcer Mimicking Oral Squamous Cell Carcinoma in Down Syndrome Child with Motoric Disorders.

Introduction: Down syndrome is a congenital genetic disorder caused by an error in cell division, resulting in the presence of an additional third chromosome 21. Down syndrome is one of the leading causes of intellectual disability. Millions of these patients face various health issues. This study aimed to provide information about the challenges in the management of chronic ulcer mimicking OSCC in Down Syndrome child with motoric disorders. Case: A 12-year-old boy with Down Syndrome and motoric disorders was referred to Oral Medicine Department. In the extraoral examination, the patient had a dysmorphic face and dry lips. Lymph node examination could not be assessed because the patient wore a cervical collar. The intraoral examination showed an irregular ulcer with 1×0.7 cm in diameter, indurated margin, and white-yellowish base at the right lateral border of the tongue. The 55 teeth were sharp and caused an occlusion trauma to the right lateral border of the tongue. The patient was diagnosed with a chronic traumatic ulcer mimicking OSCC based on clinical examination. The medication given to the patient were sodium chloride 0.9%, povidone-iodine mouthwash 1%, and petroleum jelly. Conclusion: Children with Down syndrome often suffer from orofacial abnormalities which can affect their oral health and their family's quality of life. Dental and oral care for Down Syndrome children with motoric disorders required some challenges and collaboration with their parents, families, and caregivers.

Epithelioid sarcoma with retained INI1 expression as a cause of a chronic leg ulcer.

Epithelioid sarcoma is a rare soft-tissue sarcoma typically presenting itself as a subcutaneous or deep dermal mass in distal portions of the extremities of adolescents and young adults. They are frequently mistaken for ulcers, abscesses, or infected warts resistant to standard medical treatment. Patients often develop multiple local recurrences with subsequent metastases. We report a case of a 66-year-old patient with chronic leg ulcer who died of generalization of an epithelioid sarcoma.

Extracellular vesicles: Emerging frontiers in wound healing.

Extracellular vesicles are membranous particles, ranging from 30 nm to 10 µm in diameter, which are released by nearly all cell types to aid in intercellular communication. These complex vesicles carry a multitude of signaling moieties from their cell of origin, such as proteins, lipids, cell surface receptors, enzymes, cytokines, metabolites, and nucleic acids. A growing body of evidence suggests that in addition to delivering cargos into target cells to facilitate intercellular communication, extracellular vesicles may also play roles in such processes as cell differentiation and proliferation, angiogenesis, stress response, and immune signaling. As these vesicles have natural biocompatibility, stability in circulation, low toxicity, and low immunogenicity, and serve as efficient carriers of molecular cargos, these nanoparticles are ideal therapeutic candidates for regenerative medicine. Exploring and identifying the homeostatic functions of extracellular vesicles may facilitate the development of new regenerative therapies. In this review, we summarize the wound healing process, difficulties in stem cell therapies for regenerative medicine, and the applications of mesenchymal stromal cell-derived extracellular vesicles in improving and accelerating the wound healing process.

Clinical effect of Traditional Chinese Medicine combined with pressure therapy in the treatment of eczema / 国际中医中药杂志

Objective:To observe the clinical effect of Traditional Chinese Medicine (TCM) collapsibility combined with pressure therapy in the treatment of eczema.Methods:From January 2021 to August 2021, 60 patients with lower extremity venous ulcers who were treated in Wangjing Hospital, China Academy of Chinese Medical Sciences were selected and randomly divided into the control group (30 patients) and observation group (30 patients). The control group was treated by the routine pressure therapy, and the observation group was by the TCM nursing intervention on the basis of the control group. Both groups were treated for 2 weeks. The visual analogy scale (VAS),chronic Venous Insufficiency Questionnaire (CIVIQ), Self-rating Anxiety Acale (SAS), and Self-rating Depression Scale (SDS) were measured and evaluated at baseline and after treatment.Results:The total response rate was 100.0% (30/30) in the observation group and 86.7% (26/30) in the control group, and the difference was statistically significant ( χ2=4.29, P=0.038). The VAS (2.47±0.68 vs. 2.97±0.14, t=3.95), SAS (40.31±11.93 vs. 55.87±4.53, t=4.73), SDS (44.30±5.38 vs. 47.61±5.33, t=2.39) scores were significantly lower than those in the control group ( P<0.05), CIVIQ score (86.63±2.74 vs. 84.67±3.23, t=2.54) was significantly higher than that of the control group ( P<0.05). Conclusion:TCM combined with pressure therapy can promote the healing of ulcers in patients with eczema, relieve pain, and improve the quality of life of patients.

Maintenance treatment with infliximab for ulcerative ileitis after intestinal transplantation: A case report.

BACKGROUND: Evidence has been published on the successful applications of the anti-tumor necrosis factor alpha antibody infliximab, such as induction therapy, salvage treatment for acute cellular rejection, and treatment for chronic ulcerative inflammation, in intestinal transplant recipients. However, the optimal protocol for the effective use of infliximab remains largely undetermined due to scarcity of available clinical data. We report a continuative application of infliximab as maintenance therapy for recurrent chronic ulcerative ileitis in a recipient of isolated intestinal transplantation (ITx). CASE SUMMARY: The patient was a 11-year-old boy with intestinal motility disorder classified as a hypogenic type of intestinal dysganglionosis. The patient underwent living-donor related intestinal transplant. His immunosuppression regimen consisted of daclizumab, tacrolimus, and steroids. Although he did not show rejection while on tacrolimus monotherapy, routine screening endoscopy showed several ulcerative lesions in the distal end of the graft 2 years after the intestinal transplant. Endoscopic work up to evaluate the progression of anemia revealed stenosis with ulcerative inflammatory changes and multiple longitudinal ulcers in the graft. Since the endoscopic findings suggested ulcerative lesions in Crohn's disease, infliximab treatment was considered. Treatment with infliximab and a small dose of oral prednisolone afforded successful withdrawal of total parenteral nutrition and maintenance of a well-functioning graft without infectious complications for 5 years since the administration of the first dose of infliximab. CONCLUSION: Infliximab is effective as maintenance therapy for recurrent chronic ulcerative ileitis in an isolated ITx patient.

Malignant Tumours Presenting as Chronic Leg or Foot Ulcers.

Our purpose was to collect data on the incidence of malignant skin tumours presenting as chronic leg or foot ulcers in a tertiary centre, and to analyse the frequency and type of initial clinical misdiagnoses in these cases. A retrospective chart review of cases with melanoma or other malignant neoplasms of the skin of the lower extremity treated in a tertiary centre during January 2010 until February 2020 was conducted to identify cases that presented as chronic ulcers. Out of 673 cases, 26 (3.9%) were identified with a total of 27 malignant tumours presenting as chronic ulcers of the lower leg or foot. Therefrom, seven were diagnosed as melanoma, eight as squamous cell carcinoma, and twelve as basal cell carcinoma. The mean interval until diagnosis for all tumour types was 44.4 months (median 24 months). A delay in correct treatment occurred in 12 out of 26 cases (46%) as a result of misdiagnosis with subsequent treatment as chronic leg or foot ulcers of a different etiology. Misdiagnoses were venous ulcer, traumatic wound, mixed arterial and venous ulcer, arterial ulcer, and ulcer of an unknown origin. Malignant ulcers presenting as chronic ulcers are rare, but often lead to misdiagnosis.

Effectiveness of the polyphenols-rich Sedum dendroideum infusion on gastric ulcer healing in rats: Roles of protective endogenous factors and antioxidant and anti-inflammatory mechanisms.

ETHNOPHARMACOLOGICAL RELEVANCE: Peptic ulcer is an inflammatory disease that therapeutic options are mainly focused in antisecretory drugs. Sedum dendroideum Moc & Sessé ex DC (Crassulaceae) is employed in folk medicine for the treatment of gastric ulcers. Recently, our group demonstrated that Sedum dendroideum infusion (SDI) is rich in polyphenols (flavonol glycosides, myricetin, quercetin and kaempferol) and promoted gastroprotection against acute ulcer models, without changes gastric acid secretion. AIM OF THE STUDY: Here, we follow the investigation of the healing effects of SDI (ED50 = 191 mg/kg) in the chronic gastric ulcer model induced by 80% acetic acid in rats, elucidating underlying mechanisms. MATERIAL AND METHODS: Rats were orally treated with vehicle (water, 1 mL/kg), SDI (191 mg/kg), omeprazole (40 mg/kg) or sucralfate (100 mg/kg) twice daily for 5 days after ulcer induction. Following treatments, toxicological effects, macroscopic ulcer appearance, microscopic histological (HE, mucin PAS-staining) and immunohistochemical (PCNA and HSP70) analysis, inflammatory (MPO and NAG activity, cytokine levels measurements) and antioxidant (SOD and CAT) parameters were investigated in gastric ulcer tissues. RESULTS: Oral treatment with SDI accelerated gastric ulcer healing, maintained mucin content and promoted epithelial cell proliferation. SDI also reduced neutrophil and mononuclear leukocyte infiltration, TNF-α and IL-1ß levels and the oxidative stress, restoring SOD and CAT activities in the ulcer tissue. CONCLUSIONS: The gastric healing effect of SDI was mediated through endogenous protective events as well as due to the anti-inflammatory and antioxidant actions. Our observations support and reinforce the traditional utilize of Sedum dendroideum as a natural nontoxic therapeutic alternative for the treatment of gastric ulcers.